Tackling the progression of benign prostatic hyperplasia/benign prostatic obstruction progression: Deobstructing within the “window of curability” (a hypothesis-generating review)

Abstract

Benign prostatic hyperplasia (BPH) and benign prostatic obstruction (BPO) remain significant contributors to male lower urinary tract symptoms, often leading to bladder damage and dysfunction. The traditional approach focuses on the management of bothersome symptoms through the use of BPH medications and may delay essential interventions, leading to disease progression and a negative impact on quality of life. This review proposes a paradigm shift to focus on bladder health preservation, as the bladder is an end organ that cannot be transplanted. Therefore, earlier diagnosis and timely surgical treatment within the “window of curability” are required. We introduce the Man vs Prostate “Five Stages of Bladder Health” to provide the needed framework to build the next iterations of BPH/BPO care. This patient-facing decision-making aid categorizes BPH/BPO progression. It integrates clinical observations with underlying pathophysiology and patient experience. This categorization highlights how untreated BPH/BPO can progress to more serious and pressing stages, the possible consequences of not taking action, and the goal to prevent late-stage disease: stage I, BPO; stage II, detrusor overactivity; stage III, urgency incontinence; stage IV, acute retention; and stage V, detrusor underactivity. On an individual patient basis, transitions are not distinct, stages can coexist, and stages can be skipped. Although promising, this proposed staging system requires further validation through prospective randomized clinical trials to confirm its clinical value and prognostic accuracy.

The concept of the “window of curability” emphasizes the need for therapeutic intervention at the optimal time. By identifying patients in earlier stages and initiating appropriate treatment, disease progression can be potentially stabilized or even reversed while aiming to optimally preserve detrusor function. Along with the Man vs Prostate staging system, this framework provides a structure for future research, shared decision making, and personalized treatment strategies. This paradigm shift necessitates a collaborative effort among urologists to reevaluate current practices, focus on earlier intervention within the “window of curability,” and prioritize bladder health preservation.

Keywords

Benign prostatic hyperplasia / Benign prostatic enlargement / Bladder health / Benign prostatic obstruction / Bladder outlet obstruction / Lower urinary tract symptoms / Disease progression / Window of curability / Bladder health preservation / Stages of bladder health / Staging system

Acknowledgments

We would like to acknowledge Christopher Kuang for design and creation of figures/table; MVP Tribe on LinkedIn for inspirational dialogue; and EAU, AUA, and NICE Guideline Committees for academic wisdom.

Statement of ethics

Not applicable.

Conflict of interest statement

The authors declare no conflicts of interest.

Funding source

This review received no external funding.

Author contributions

WWK: Conceptualization, investigation, writing - original draft preparation.

WWK, LC, TA, BIC: Writing - review and editing.

Data availability

Data discussed in this article are drawn from previously published studies, which are cited within this article.

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